MODULE 13 UNIT 1 - AUTHORIZATION

WHAT IS AN AUTHORIZER?

An authorizer gathers information from the contractor (attributes, diagnosis, recommendations, cost estimate) and uses that information to make a Coverage Decision based on the member’s contract. The authorizer will make the contractor aware of the amount that AHS is willing to pay for the complete covered repair or replacement (Cost Decision). Authorizers are able to explain coverage decisions and provide options to members. As a Shield Agent, you will receive calls from members requesting status updates which will require you to interpret authorizers’ decisions that are noted in CSC and convey this information to the members.

SITUATIONS THAT REQUIRE AUTHORIZATION Notes on situations that require the vendor to contact the Autho department:

• Out of pocket expenses
• recall
• expedited
• direct dispatch vendors

CAUSAL CONNECTION

Authorizers establish a causal connection by:

• Identifying the malfunction and the symptoms of the malfunction • Asking the contractor for the symptoms and cause of the malfunction and performing a thorough investigation into the facts that are relevant to the malfunction • Making the coverage decision based on the malfunction identified by the contractor and identify the contract coverage, exclusion or limitation that applies to the malfunction • Documenting coverage decisions by entering relevant notes into our system

        ESTABLISHING A CAUSAL CONNECTION

There are four basic steps to establish a causal connection: PURPOSE OF AUTHORIZATION:

• to authorize the vendors the actual decision.

Identify malfunction (Leaking water heater)

Investigate cause (Sedimentary build up in tank)

Identify contract provision, exclusion or limitations (Review member’s Contract)

Document coverage decisions (Enter relevant notes)

                        SERVICE OUTCOMES

Once a causal connection has been established, service requests will be completed in one of the following ways.

• Repair: Usually the contractor will replace a component of the item (e.g., motor pump assembly, control board, heating element, etc.). Some repairs may only require adjustments, such as tightening a loose connection. Parts can be AHS or contractor supplied. There may be additional out of pocket costs for the member – Non-Covered Costs (NCC).

• Replacement: If the covered item cannot be repaired, AHS will replace it (e.g., toilet, faucet, ceiling fan, water heater, pool heater, etc.). Equipment can be AHS or contractor supplied. There may be additional out of pocket costs for the member (NCC). Appliances that need to be replaced are put into Appliance Replace Options.

• Appliance Repair Options: The member can choose to have the appliance repaired or upgraded or a CIL. The covered repair costs will be used in calculating upgrade costs or CIL.

• Appliance Replace Options: When an appliance is unrepairable and needs to be replaced, the item is placed into options. The Appliance Purchasing department can offer replacement with a similar appliance, an upgrade or CIL.

• System Upgrade: Members can upgrade (get a better quality or higher capacity item) through the AHS assigned contractor, applying the covered amount to the upgraded item and paying any out of pocket costs over the approved amount. The contractor will supply parts/equipment. Examples: getting a larger water heater, getting a better-quality faucet than the contract covers, getting a more efficient air conditioning unit.

• Cash-in-lieu: The member can take the covered amount in the form of a CIL and find their own contractor to complete the covered service. In some situations, CIL is required by the contract. Contracts vary so be sure to check the applicable contract terms when considering a CIL. Examples: repairing a slab leak over the contract limit, item is no longer manufactured, item will not meet code regulations if repaired or replaced. Remember: Appliance Purchasing handles CIL for appliances. ( cash out )

• send the receit and we send them the cash.

• Recommended Repair or Replacement is Not Covered: Certain items, components, or causes of failures (e.g., pest damage, power surge, roots in the drain line, etc.) may not be covered under the member’s contract. If access is the issue, the member may be able to make access and request the contractor return. Other not covered situations may include: item is under full manufacturer’s warranty, the item is under a manufacturer’s recall, or the item doesn’t meet the criteria for coverage (may include such things as, item is located outside the main foundation of the home or is a commercial grade item, etc.).

         UNDERSTANDING THE PROCESS
  

• Our goal is to be helpful and reliable by providing members with status updates in a simple and understandable manner.

One way to do this is to have the ability to accurately translate information documented by AHS Authorizers.

• Once a contractor has been to the home to assess the problematic item/system, he/she will make AHS aware of the diagnosis, request authorization to complete the repair, and in some cases, request AHS to order parts. • The Authorizations associate is then responsible for documenting the information on the Autho Summary Home Page in Service Fulfillment. You will see their comments/information on the Authorizations Activity tab in CSC.

Work order dispatched - Contractor makes adiagnosis & provides an estimate - Contractor requests Authorization* - Coverage Decision - Cost Decision - AHS authorizes covered services - Member communication** - Contractor completes covered work - Contractor bills AHS up to the authorized amount - Accounting compares the authorized amount to the invoice & pays the contractor.

• Request authorization— Contractor is required to request authorization from our Authorizations department in the following situations: non-covered services, over contractor’s authorization limit, recall, second opinion, request placed within first 30 days of new contract.

**Member communication— Authorizers are required to contact the member if the authorization decision results in either of the following: non-covered services, over the contract limit, invalid recall, second opinion.

READING AND INTERPRETING AUTHORIZATION DOCUMENTATION

If a member is calling about a specific service request, there are several pieces of information that we need to view. Each detail is a piece of the puzzle which we will need to put together before providing a status update to the member.

                         DETAILED DIAGNOSIS

• Determine if there is a detailed diagnosis and an authorization activity available.

• report coming from the vendor that contents of attributes symptoms, cause of failure, recommended actions.
• authorizers - decide if it will diagnosed or not
• A detailed diagnosis is the documented professional opinion of the contractor. It is the first puzzle piece associated with reading and interpreting authorization documentation.

( 3 puzzled pieces

• diagnosis -

• Detailed Diagnosis TECH MD AWR MICROWAVE NOT COMING ON DUE TO CONTROL PAD BURNT OUT. CONTROL BOARD NEED TO BE REPLACED. CAUSE OF FAILURE IS N/W/ T

• Detailed Diagnosis Dishwasher motor board has shorted causing the unit not to come on due to normal wear and tear tech recommends to replace motor board

authorization activity tab denials tab

                      AUTHORIZATION ACTIVITY TAB
                      CSC – Authorization Activity Tab

The Authorization Activity tab is the second puzzle piece that you should view to provide an accurate status update after an authorization has been entered. The Authorization Activity tab displays equally important authorization information to help you create the best puzzle of explanation to the member. Knowing where to find authorization-related information helps to provide members with updates in a simple and understandable manner.